Episodes of intense anger associated with high risk of heart attack

The risk of heart attack has been found to be 8.5 times higher in the two hours following an acute episode of anger than during the “usual frequency” patterns of anger.

The findings emerged from a well controlled study in which acute coronary blockage was angiographically confirmed in patients hospitalised for suspected heart attack. This elevated state of anger or anxiety preceding the myocardial infarction was also found to be significantly higher than at the same time the preceding day.

A report of the study is published in the European Heart Journal: Acute Cardiovascular Care, a journal of the European Society of Cardiology.

The study thus appears to confirm what has been suggested in earlier studies and indeed by anecdotal experience, that anger can act as a trigger for heart attack, and thus highlights a need, say the authors, “to consider strategies to protect individuals most at risk during times of acute anger”.

The study was an investigation of patients suspected of myocardial infarction and admitted for primary angioplasty at the Royal North Shore Hospital in Sydney, Australia, between 2006 and 2012, and assessed by coronary angiography. Of 687 patients initially assessed, 313 were confirmed with occluded coronary blood flow by angiography and were enrolled in the study.

Anger, as evident over the 48 hours preceding the onset of symptoms, was self-assessed by questionnaire according to a seven-point scale, with one defined as “calm”, and seven as “enraged, out of control, throwing objects, hurting yourself or others”. For study purposes, the threshold of acute anger was defined by level five — “very angry, body tense, maybe fists clenched, ready to burst”.

Analysis of responses showed that seven of the 313 confirmed cases (2.2%) had reached anger of at least level five within the two-hours preceding the onset of symptoms. In addition, one participant had reached anger level five within four hours of the heart attack, and anger level four (“moderately angry, so hassled it shows in your voice”) was reported by two participants within two hours, and by three participants within four hours.

Based on the subjects’ usual frequency for anger, the relative risk of onset of symptoms occurring within two hours of reaching anger level five or above was calculated as 8.5 (95%), an eight-fold greater level of risk than that associated with normal levels.

Statistical associations with lower levels of anger, or anger occurring over two hours before symptom onset did not reach statistical significance. However, high levels of anxiety (greater than the 90th percentile on a validated anxiety scale) were associated with a 9.5-fold increased risk of triggering heart attack in the two hours after the anxiety episode when compared with anxiety levels the previous day.

The investigators suggest that findings such as these coincide with an “increased acceptance of the role of psychological factors, both acute and chronic, in the onset of acute heart attack, sudden cardiac death and stroke” and “are consistent with previous reports in other populations”. Unlike most other studies, however, this study could confirm angiographically that the subjects had indeed suffered a heart attack, and thus “adds to the small, but growing, body of evidence linking acute emotional triggers with onset.”

— European Society of Cardiology